Addressing Psychiatric Disorders in Methadone Patients Joan E. Zweben, Ph.D. COMP CONFERENCE – April 28, 2008 Pleasant Hill, California Co-Occurring Disorders (CODs): A Federal Priority Growing attention from.
Download ReportTranscript Addressing Psychiatric Disorders in Methadone Patients Joan E. Zweben, Ph.D. COMP CONFERENCE – April 28, 2008 Pleasant Hill, California Co-Occurring Disorders (CODs): A Federal Priority Growing attention from.
Slide 1
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 2
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 3
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 4
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 5
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 6
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 7
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 8
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 9
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 10
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 11
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 12
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 13
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 14
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 15
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 16
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 17
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 18
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 19
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 20
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 21
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 22
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 23
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 24
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 25
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 26
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 27
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 28
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 29
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 30
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 31
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 32
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 33
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 34
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 35
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 36
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 37
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 38
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 39
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 40
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 41
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 42
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 43
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 44
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 45
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 46
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 47
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 48
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 49
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 50
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 51
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 52
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 2
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 3
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 4
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 5
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 6
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 7
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 8
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 9
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 10
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 11
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 12
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 13
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 14
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 15
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 16
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 17
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 18
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 19
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 20
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 21
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 22
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 23
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 24
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 25
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 26
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 27
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 28
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 29
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 30
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 31
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 32
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 33
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 34
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 35
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 36
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 37
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 38
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 39
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 40
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 41
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 42
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 43
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 44
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 45
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 46
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 47
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 48
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 49
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 50
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 51
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
Download Slides from:
www.comproviders.com
Slide 52
Addressing Psychiatric
Disorders in Methadone
Patients
Joan E. Zweben, Ph.D.
COMP CONFERENCE – April 28, 2008
Pleasant Hill, California
Co-Occurring Disorders (CODs):
A Federal Priority
Growing attention from providers and
researchers since about 1985
National consensus developed at meetings of
CSAT, CMHS, NASADAD, NASHMHPD,
published in 1999 Position Paper
Report to Congress on the Prevention and
Treatment of CODs (November 2002) signals
importance of federal priority
Policy Direction on COD’s
Co-occurring
disorders are the norm, not the
exception
Stronger levels of service coordination are needed to
improve outcome. This can be done through
consultation, collaboration, or integration.
Clients’ needs should be appropriately addressed at
whatever point the enter the system. There is “no
wrong door,” and referrals should be actively guided.
Barriers to Addressing Psychiatric
Disorders
Program
may not have good diagnosticians
Belief that methadone and counseling (or TC or
12-step participation) will fix everything
Inappropriate expectations about time course for
improvement
Resistance/misunderstanding about psychotropic
meds; lack of training on how to facilitate
adherence
Epidemiology
Increased
rates of psychiatric disorders in opioid users
Rates vary depending on whether it is a community or
treatment-seeking sample, and by other demographic
factors
Common disorders: mood disorders, anxiety disorders,
personality disorders
Beware of misdiagnosis, especially antisocial personality
disorder
Untreated Psychiatric Disorders
low
self esteem
low mood
distorted relationships & family functioning
impaired judgment
lower productivity
less favorable outcome for alcohol and drug
treatment
Untreated Psychiatric Disorders
reluctance
to commit to abstinence (fear of
symptoms)
difficulty in achieving abstinence - possibility of
more distressing withdrawal symptoms,
emergence of psychiatric symptoms with
abstinence
harder to maintain abstinence; more frequent
relapses
Assessment:
Substance-Induced Conditions
Are the presenting symptoms consistent with the
drug(s) used recently?
cognitive
dysfunction/disorder: delerium, persisting
dementia, amnestic disorder
psychotic disorder
mood symptoms/disorder
sexual dysfunction
sleep disorder
See DSM-IV-TR, pages 193, 748-749
Substance-Induced Symptoms
AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence, suicide,
unsafe sex, other high risk behavior); anxiety, depression,
psychosis, dementia
Stimulants: impulse control problems, mania, panic
disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Distinguishing Substance Abuse from
Psychiatric Disorders
wait
until withdrawal phenomena have subsided (usually
by 3-4 weeks) and methadone dose has been stabilized
physical exam, toxicology screens
history from significant others
longitudinal observations over time
construct time lines; inquire about quality of life during
drug free periods
Multiple Disorders: Basic Issues
When two or more disorders are observed:
Safety first; then stabilization and maintenance
Which disorder(s) should be treated?
What is the best treatment?
Will the disorders and/or treatments interact?
How will the treatment(s) be integrated or
coordinated?
(partially adapted from Schuckit, 1998)
Depression: A Medical Illness
Beyond
neurotransmitters: it is a disease with
abnormalities in brain anatomy, as well as neurologic,
hematologic, and cardiovascular elements.
Episodes damage the brain. It is important to prevent or
shorten them.
Episodes also impair resiliency, or the brain’s ability to
repair itself.
Depression is associated with an increase in heart attacks
and strokes, and mortality from these diseases.
Antidepressants reduce mortality.
(Kramer, Against Depression, 2005)
Depression in Opiate Users
atypical
reactions to heroin reported by clinicians
“feeling normal” vs “getting high”
treatment-seeking opiate users have higher levels
of depression (Rounsaville & Kleber, 1985)
evaluate for medication after stabilized on opioid
replacement; consider alcohol and stimulant use
be alert to relapsing and remitting course of
depressive symptoms
Treating Depression in Patients on
Opioid Replacement Therapy
antidepressants
are compatible with methadone.
Monitor cardiac function if SSRI’s are used.
presence of depression is associated with favorable
treatment response for those who remain in tx
(Kosten et al 1986)
addition
of psychotherapy is helpful for this group
(Woody et al 1986)
evaluate
for PTSD
Depression: Issues for Clarification
Alcohol
and drug use as the great imitator
When is it a problem? Use vs abuse/dependence
Inquire carefully about the quality of experience.
Distinguish between clinical depression and upset,
distress, sadness, grief, misery, guilt, shame, etc.
Key elements: 1) 5 of the 9 symptoms; 2) most of the
day, nearly every day, at least 2 weeks; 3) clinically
significant distress or impairment
Post-traumatic stress disorder
DSM-IV: Major Depressive Episode
Five or more during same 2 week period, representing a
change from previous functioning;
Must include 1 & 2
1) depressed mood most of the day, every day (subjective
report or observation)
2) diminished interest or pleasure
3) significant weight lost (not dieting) or weight gain
4) insomnia or hypersomnia nearly every day
Major Depressive Episode (2)
5) psychomotor agitation or retardation nearly daily
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or inappropriate guilt
8) diminished ability to think or concentrate, or
indecisiveness
9) recurrent thoughts of death (not just fear), suicidal
ideation without specific plan, suicide attempt or a
specific plan for committing suicide
Depression
Caveat: Does the study separate substance-induced mood
symptoms from an independent condition?
National Comorbidity Study
major depression & alcohol dependence the most common
disorders
history of major depressive episode: 17%
episode within last 12 months: 10%
any affective disorder, lifetime prevalence: women 23.9%
(MDE 21.3%), men 14.7% (MDE 12.7%)
(Kessler et al 1994)
Depression: Symptom Domains
Dysphoric
mood (includes irritability)
Vegetative signs: sleep, appetite, sexual interest
Dysfunctional cognitions (obsessive thoughts, brooding)
Anxiety: fearfulness, agitation
Suicidality
AOD
use is a major risk factor, especially for
young people
Alcohol: associated with 25%-50%
Alcohol & depression = increased risk
Intoxication is associated with increased violence,
towards self and others
High risk when relapse occurs after substantial
period of sobriety, especially if it leads to
financial or psychosocial loss
Suicidality
Suicide
does not imply depression; may be anxiety
and/or despair
Addiction: higher probability of completed suicide
There is no data that supports the view that
antidepressants prevent suicide (but, studies are only 3
months long)
Lithium and clozaril reduce suicide attempts
Rick Ries, MD CSAM 2004
Suicidality:
Counselor Recommendations
Treat
all threats with seriousness
Assess risk of self harm: Why now? Past attempts,
present plans, serious mental illness, protective factors
Develop safety and risk management process
Avoid heavy reliance on “no suicide” contracts
24 hour contact available until psychiatric help can be
obtained
Note: must have agency protocols in place
Assess Suicide Risk
Prior
suicide attempt(s)
Recent increase in suicidal preoccupation
Level of intent; formulation of plan
Availability of lethal means
Family history of completed suicide
Active mental illness or high risk forms of drug use
Serious medical illness
Recent negative life events
Agency Protocol for Suicidal Patients
Screening:
who does it and how are they trained?
Assessment: who does it and what are their
qualifications?
Are there clear procedures for monitoring high
risk patients?
Are there clear procedures for hospitalization if
necessary?
Treatment Issues
gender
differences (Kessler et al 1994)
psychotherapy - target affective symptoms or
psychosocial problems; 50% efficacy
medications - SSRI’s, tricyclics; 50% efficacy
counselor attention to adherence is essential
combination
tx for those who with more severe or
chronic depression or partial responders to either
treatment (American Psychiatric Association 1993; Schulberg & Rush 1994)
PTSD: National Comorbidity Study
Representative national sample, n = 5877, aged 14-54
Women
more than twice as likely as men to have
lifetime PTSD (10.4% vs 5.0%)
Strongly comorbid with other lifetime psychiatric
disorders
More than one third with index episode of PTSD fail
to recover even after many years
Treatment appears effective in reducing duration of
symptoms
(Kessler et al 1995)
Post Traumatic Stress Disorder
Exposed
to traumatic event with both present:
• experienced, witnessed, or was confronted with an event(s)
involving actual or threatened death or serious injury, or threat
to physical integrity of self or others
• person’s response involved in tense fear, helplessness, or horror
Event
persistently re-experienced:
• recurrent and intrusive distressing recollections, including
images, thoughts, perceptions
• recurrent distressing dreams of the event
PTSD (2)
• acting or feeling as if the traumatic event were
recurring
• intense psychological distress at exposure to internal
or external cues that symbolize or resemble an aspect
of the traumatic event
• physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of
the traumatic event
PTSD (3)
Persistent
avoidance of stimuli associated with the
trauma; numbing of general responsiveness. Three or
more:
• efforts to avoid thoughts, feelings or conversations
associated with the trauma
• efforts to avoid activities, places or people
• inability to recall an important aspect of trauma
• diminished interest or participation in significant
activities
PTSD (4)
• feeling of detachment or estrangement
• restricted range of affect
• sense of foreshortened future
Persistent
•
•
•
•
•
sx of increased arousal (2 or more)
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
Relationships between Trauma and
Substance Abuse
Traumatic
experiences increase likelihood of
substance abuse, especially if PTSD develops
Childhood trauma increases risk of PTSD, especially
if it is multiple trauma
Substance abuse increases the risk of victimization
Need for linkages between systems: medical,
shelters, social services, mental health, criminal
justice, addiction treatment
(Zweben et al 1994)
PTSD Among Inner City MMT Patients
Women:
lifetime
prevalence 20% (community sample: 10.4%)
most common stressor: rape
Men:
lifetime
prevalence 11% (community sample: 5%)
most common stressor: seeing someone hurt or killed
(Kessler et al 1995; Villagomez et al 1995)
Screening Questions to Detect
Partner Violence
Have
you ever been hit, kicked, punched or otherwise
hurt by someone within the past year? If so, by whom?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is
making you feel unsafe now?
(Feldhaus 1997)
Impact of Physical/Sexual Abuse on
Treatment Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical
abuse has more impact on men
psychopathology is typically associated with less
favorable tx outcomes, however:
abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
PTSD Treatments
Stress
inoculation training and prolonged
exposure (flooding) (Foa et al 1991; 1998)
Cognitive-Behavioral Therapy (Najavits et al 1996)
Eye Movement Desensitization and Reprocessing
(Shapiro 1995)
Anger
management/temper control (Reilly et al 1994)
Substance Dependence-Post Traumatic Stress
Disorder Treatment (SDPT) (Triffleman, under investigation)
How PTSD Complicates Recovery
More difficulty:
establishing trusting therapeutic alliance
obtaining abstinence commitment; resistance to
the idea that AOD use is itself a problem
establishing abstinence; flooding with feelings
and memories
maintaining abstinence; greater relapse
vulnerability
How Substance Abuse Complicates
Resolution of PTSD
early
treatment goal: establish safety (address AOD use)
early recovery: how to contain or express feelings and
memories without drinking/using
firm foundation of abstinence needed to work on
resolving PTSD issues
full awareness desirable, vs emotions altered by AOD use
relapse risk: AOD use possible when anxiety-laden issues
arise; must be immediately addressed
Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
avoid setting patient up for failure
reduce safety hazards; contract about dangerous
behavior
carefully assess skills for coping with feelings and
memories; work to develop them
Anger Management & Temper Control
Identifying
cues to anger: physical, emotional,
fantasies/images, red flag words and situations
Developing an anger control plan
Cognitive-behavioral strategies for anger
management
Breaking the cycle of violence; understand family
of origin issues
(Reilly et al 1994)
Beware of gender bias; ask about parenting behaviors
Seeking Safety:
Early Treatment Stabilization
25
sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance abuse are
integrated, not separate
Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
Four
•
•
•
•
areas of focus:
Cognitive
Behavioral
Interpersonal
Case management
Grounding
exercise to detach from emotional pain
Attention to therapist processes: balance praise
and accountability; notice therapists’ reactions
Seeking Safety (3):
Goals
Achieve
abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
Safe Coping Skills
Ask
for help
Honesty
Leave a bad scene
Set a boundary
When in doubt, do what is hardest
Notice the choice point
Pace yourself
Seek understanding, not blame
Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching from Emotional Pain:
Grounding
Focusing
out on external world - keep eyes open, scan
the room, name objects you see
Describe an everyday activity in detail
Run cool or warm water over your hands
Plan a safe treat for yourself
Carry a grounding object in your pocket to touch when
you feel triggered
Use positive imagery
(Najavits, 2002)
Psychosocial Treatment Issues
client
attitudes/feelings about medication
client attitude about having an illness
other clients’ reactions: misinformation, negative
attitudes
staff attitudes
medication compliance
control issues: whose client?
Attitudes and Feelings about
Medication
shame
feeling
damaged
needing a crutch; not strong enough
“I’m not clean”
anxiety about taking a pill to feel better
“I must be crazy”
medication is poison
expecting instant results
Medication Adherence
Avoiding
medication can cause further harm.
Appropriate medications improve treatment outcome
Reasons for non-compliance: denial of illness,
attitudes and feelings, side effects, lack of support,
other factors
Role of the counselor: periodic inquiry, exploring
charged issues, keeping physician informed
Work out teamwork, procedures with docs
Medications: Counselor’s Queries (1)
Compliance
• “sometimes people forget their medications…how
often does this happen to you? (% not taking)
Effectiveness
• “how well do you think the meds are working?”
• “What do you notice?
• Here is what I notice
Medications: Counselor’s Queries (2)
Side
•
•
•
•
Effects
“Are you having any side effects to the medication?”
“What are they?”
“Have you told the physician?”
Do you need help talking with the doc?”
(Richard K. Ries, MD CSAM 2004)
Women’s Issues
heightened
vulnerability to mood/anxiety
disorders
prevalence of childhood physical/sexual abuse
and adult traumatic experiences
treatment complications of PTSD
practical obstacles: transportation, child care,
homework help
Educate Clients about Psychiatric
Conditions
The
nature of common disorders; usual course; prognosis
Important factors: genetics, traumatic and other stressors,
environment
Recognizing warning signs
Maximizing recovery potential
Misunderstandings about medication
Teamwork with your physician
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